Racial Incident
Report Form
Don't worry about those things you have no control over.


Introduction
Disclaimer
Security
Person Reporting
Other People
Involved
Location
Description
of Situation
Solution Sought
Other
Relevant Issues




Introduction:

If you have experienced or
are experiencing a problem of racial discrimination, or
if you know someone who has or is, or
if you have seen some form of racial discrimination, or
if someone has accused you of racial discrimination, and
you are seeking advice and referral. . . continue.


Table of Contents
Report Form

Disclaimer:

You are ultimately responsible for your own actions. The advice and referral that I offer is only designed to help you create a plan of action. Whether or not to perform that action is your decision. This is an important issue in that it is your life, not mine; and I believe you should maintain control of your own life.

By filling out this form, you are giving me permission to report the incident (NOT you), in generalities, in another section labeled Responses to Racism.

The purpose of this is to provide a general report to the public of the issues surrounding discrimination.

Given all of this let's talk about security .


Table of Contents
Report Form

Security:

All specific information will remain
as confidential as possible on the internet.

However, there are a few bad guys who might be interested in disrupting this information. If you are willing to give me a phone number where you can be reached and are willing to accept a collect call from me, I will contact you directly. To do this you must e-mail me a name and number (including the area code) but that is the extent of the message needed.

Otherwise, if you want a quicker and probably just as secure response

please fill out a Racial Incident Report Form.


Table of Contents
Person Reporting:
For more than one person finish this entire form and submit; then clear, and fill out and submit another form only marking the areas where appropriate. Note: Be sure to put your last name on all forms submitted.

Name:
� � �
� First:� � � � � � � � � � �Middle:� � � � � � � �� �Last:

 E-mail Address: �� � � � � � � � � � � � � � � Telephone:
� �
� � � � � � � � � � � � � � � � � � � � � � � � � � � �Area Code:� Number:
Mailing Address:
� �
� Street:� � � � � � � � � � � � � � � � � � � � � � � City:
� �
� State/Country: � � � � � � � � � � � � � � � � � � �Zip:

Age:� � � �Sex: � � � � � � � � � � Type of Work or Educational Institution:
� � � Female Male

Ethnic Background: � � � � � � � � Specific Heritage*:
�
� � � � � � � � � � � � � � � � � � � � � * For example: Japanese American, Hawaiian, Creole, Choctaw, Cuban . . .

Continue to next section. . .


Table of Contents
Previous
Other People Involved:
For more than one person, finish this entire form and submit, then clear, fill out and submit another form only marking the areas where appropriate.

Name:
� � �
� First:� � � � � � � � � � �Middle:� � � � � � � �� �Last:

 E-mail Address: �� � � � � � � � � � � � � � � Telephone:
� �
� � � � � � � � � � � � � � � � � � � � � � � � � � � �Area Code:� Number:
Mailing Address:
� �
� Street:� � � � � � � � � � � � � � � � � � � � � � � City:
� �
� State/Country: � � � � � � � � � � � � � � � � � � �Zip:

Age:� � � �Sex: � � � � � � � � � � Type of Work or Educational Institution:
� � � Female Male

Ethnic Background: � � � � � � � � Specific Heritage*:
�
� � � � � � � � � � � � � � � � � � � � � * For example: Japanese American, Hawaiian, Creole, Choctaw, Cuban . . .

If name unknown, describe:

Continue to next section. . .


Table of Contents
Previous
Location:
� �
� City:� � � � � � � � � � � � �State:� � � � � � � � � � � �Country:

 Public. Please check one.
� � Other:��
Private. Please check one.
� � Other:��
Continue to next section. . .


Table of Contents
Previous
Description:
Describe the problem. Include people, places, dates and times.
Continue to next section. . .


Table of Contents
Previous
Solution Sought:
Whether you just want someone else to be aware of the problem, you are simply seeking understanding, or want legal recourse; list the remedies you would like to seek in this situation.
Continue to next section. . .


Table of Contents
Previous
Other Relevant Issues:
I am currently spending alot of time on the computer, so I can generally provide feedback within a day. If there are any other issues or concerns not covered in this format, please let me know so I can make changes.

Hosted by www.Geocities.ws

1